Drug Testing

Patients should not be screened without their permission, as there are profound legal consequences associated with positive tests. ^20,21 Refusal to allow testing should be documented, and discussion with hospital legal council may be needed in the context of state policies. An exception is during life-threatening events when test results may be needed to guide management.

Urine drug screens may be false positive. Common agents like labetalol or pseudoephedrine may cause drug screens to be positive for amphetamines and methamphetamines.²² Dextromethorphan may show up as PCP. No rapid urine drug screen should be taken as an absolute positive until confirmed by gas chromatography–mass spectrometry.

Medical professionals should be aware that in performing testing for the specific purpose of gathering evidence of criminal conduct by patients, they have an obligation to inform the patients of their constitutional rights to protection from unreasonable search and seizure. Hospitals that fail to inform patients of their rights may be open to civil liability.

Testing policies that are developed with law enforcement agencies, employing their protocols, are more likely to be deemed unrelated to treatment and thus be perceived as being used only to further prosecution. To avoid such categorization, hospitals should develop testing procedures based on medical care and treatment options, independent of police or prosecutors.

No state authorizes or expects physicians to use medical evidence of addiction for criminal prosecution.

Reporting

Some states may require reporting of mothers with drug problems to protective services. One must be aware of how local law and social services approach this issue. This will help avoid conflicts between parental rights and child protection.

The goal is to get these patients into programs that specifically address drug dependency. These programs have demonstrated significant improvement in obstetric outcomes in both health-related parameters and costs of care. An example is the Center for Addiction and Pregnancy.²³

No state specifically criminalizes drug use during pregnancy. Prosecutors have attempted to rely on a host of criminal laws already on the books to attack prenatal substance abuse. Only the South Carolina Supreme Court has upheld such a conviction, ruling in Whitner v. State that a woman’s substance abuse late in pregnancy constitutes criminal child abuse. Meanwhile, several states have expanded their civil child-welfare requirements to include prenatal substance abuse, so that prenatal drug exposure can provide grounds for terminating parental rights because of child abuse or neglect. Further, some states, under the rubric of protecting the fetus, authorize civil commitment (such as forced admission to an inpatient treatment program) of pregnant women who use drugs; these policies sometimes also apply to alcohol use or other behaviors. A number of states require health care professionals to report or test for prenatal drug exposure, which can be used as evidence in child welfare proceedings. In order to receive federal child abuse prevention funds, states must require health care providers to notify child protective services when the provider cares for an infant affected by illegal substance abuse. Finally, a number of states have placed a priority on making drug treatment more readily available to pregnant women.²⁴

References

1. Topics in Brief: Prenatal Exposure to Drugs of Abuse. National Institute of Drug Abuse. Revised May 2011. www.drugabuse.gov/publications/topics-in-brief/prenatal-exposure-to-drugs-abuse.
2. Pediatrics 2009;123:e614-21.
3. Pediatrics 2012;129:e540-60.
4. ACOG Committee on Obstetrics Opinion: (114) Cocaine abuse – implications for pregnancy. 1992.
5. ACOG Committee on Obstetrics Opinion: (479) Methamphetamine abuse in women of reproductive age. 2011.
6. Br. J. Cardiol. 2011;18:142-4.
7. Circulation 2008;117:1897-907.
8. J. Soc. Gynecol. Investig. 2004;11:388-92.
9. Birth Defects Res. A Clin. Mol. Teratol. 2006;76:507-16.
10. Obstet. Gynecol. 2002;99:159-67.
11. Neurology 2009;73:133-41.
12. Epilepsy Res. 2011;94:53-60.
13. JAMA 2011;305:1996-2002.
14. Psychiatr. Serv. 2002;53:39-49.
15. J. Clin. Psychiatry 2005;66:317-22.
16. J. Matern. Fetal Neonatal Med. 2012;25:1197-201.
17. Briggs GG, et al. Drugs in Pregnancy and Lactation. 8th ed. Baltimore: Lippincott Williams & Wilkins, 2008.
18. J. Emerg. Med. 1998;16:419-24.
19. ACOG Committee on Obstetrics Opinion: (321) Maternal decision making, ethics, and the law. 2005.
20. JAMA 2003;289:1697-9.
21. Am. Med. Assoc J. Ethics 2008;10:41-4.
22. Obstet. Gynecol. 2011;117(2 Pt 2):503-6.
23. J. Subst. Abuse Treat. 1996;13:321.
24. Guttmacher Institute. State Policies in Brief. Substance Abuse During Pregnancy. 3/1/12. http://www.guttmacher.org/statecenter/spibs/spib_SADP.pdf.

Dr. Roemer is an Associate Professor in the Department of Emergency Medicine, OU School of Community Medicine, Schusterman Center, in Tulsa, Okla.; Dr. Banner is Medical Director at the Oklahoma Poison Control Center and Pediatric Critical Care Attending at Integris Baptist Medical Center in Oklahoma City, Okla.; Dr. Katz is a Clinical Professor in the Department of Obstetrics and Gynecology at the Oregon Health Sciences University and Medical Director of Women’s Services at Sacred Heart Medical Center, Center for Genetics and Maternal-Fetal Medicine, in Eugene, Ore.; Dr. Plinsky is a Resident in the Department of Emergency Medicine at the OU School of Community Medicine in Tulsa, Okla.